CN-370000-LE811-7I-70751.pdf
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- Contract number
- LE811
- Issued by
- Florida
About this file
This Work Authorization Form (OER_13) is issued by the Florida Department of Environmental Protection's Office of Emergency Response and authorizes work to be performed by CLIFF BERRY INC. under Contract #LE811. The authorization document references DEP Incident #2023-7I-70751, dated January 8, 2024, and pertains to an abandoned drum response at the Dunn Avenue and North Tomoka Farms Road location in Daytona Beach, Volusia County, Florida. The On-Scene Coordinator (OSC) is Jimi Rucker, with work authorization set for January 9, 2024.
The work involves the mobilization and disposal of four drums of used motor oil classified as an abandoned drum response with a 55-gallon capacity. The contract rate structure is fixed price with a not-to-exceed estimate amount of $1,280.00. Funding is allocated from Project Number LE811, Organization Code 3704 0100 000, with Object Code 131545, Fund Category/Year 102577, and Amount 1,280.00. The form was approved by Samuel Graves (OER Representative) on January 8, 2024, Yvonne Cerna (Contractor Representative) on January 9, 2024, and Vickie Koenig (OER Budget Representative) on March 6, 2024.
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Text version
OER_13 (Effective 7-01-2017)
Florida Department of Environmental Protection
Office of Emergency Response
WORK AUTHORIZATION FORM
Required Signatures: Adobe Signature or Original Ink Supplemental WAF
Contractor: ____________________________________ DEP Incident # ______________________ Contract #: ___________ Rep: ____________________ Incident Date _______________________ Site Name: ____________________________________ OSC: ______________________________ Location: ______________________________________ Phone: Office______________________ City: __________________County: _________________ Cell ________________________
Description of Work: Respond Immediately Call OSC to set date/time__________________________________
Spill Response Overpack Drums Transport drums to TSA Abandoned Drum:
Remove Soil Sampling Transport Drums to TSDF Analysis of samples collected by OER
Other:
Suspected Materials, and amounts: _____________________________________________________________________________________
Level of Effort: (Check all that apply) Use Subcontractor per OSC
Personnel Vehicles Equipment
Supervisor: ____ Response Truck Overpack Drums: Visqueen
Recovery Tech: ____ Straight Truck 55-gal. Drums: Roll-off Containers: ___________
Field Chemist: ____ Vacuum Truck Sampling Gear EPA Level 1 Vapor Detector
Equip. Oper.: ____ Pickup or Van Sampling Gear EPA Level 2 PPE Level: __________________
Other: ____________ Backhoe or Similar Other: ________________ MOT
Contract Rate: ____________
Comments: ___________________________________________________________________________________________________________
Analytical & Disposal Arrangements: (analytical will usually be listed on Chain-of-Custody or other form)
Via Contractor Via Subcontractor Other: __________________________
Profile Wastes as:
Work Assignment Type: fixed price Not to Exceed estimate amount: $___________________________
Funding Information: (information provided by OER budget rep., budget rep to sign after WAF executed, but prior to transmittal to F&A)
Project No. Organization Code EO Object Code Fund Category/Yr Amount
Approved:
DEP Representative: __________________________ Signature: _______________________________ Date: __________________
Contractor Rep: __________________________ Signature: ___________________________________ Date: __________________
OER Budget Rep: __________________________ Signature: __________________________________ Date: __________________
Deliverable will be reviewed and evaluated by the DEP Contract Manager to ensure appropriate documentation reviewed and/or provided and that the documentation submitted is complete, accurate, and submitted timely
CLIFF BERRY INC. 2023-7I-70751
LE811 1/08/2024
DUNN AVE JIMI RUCKER
DUNN AVE & N TOMOKA FARMS RD 407-897-2947
DAYTONA BEACH VOLUSIA 407-595-2106
1/09/2024
USED MOTOR OIL, 4 DRUMS
MOBE & DISPOSAL
LE811 3704 0100 000 FC 131545 0990001 102577 1,280 00
JIMI RUCKER 1/08/2024
YVONNE CERNA 01/09/2024
Vickie Koenig 3/6/2024
Samuel Graves
✔ 55 GAL
Vickie Koenig Digitally signed by Vickie Koenig Date: 2024.03.06 16:23:08 -05'00'
Yvonne Cerna Digitally signed by Yvonne Cerna Date: 2024.01.09 07:20:11 -05'00'
Jimi Rucker Digitally signed by Jimi Rucker Date: 2024.01.08 17:54:35 -05'00'
Samuel Graves Digitally signed by Samuel Graves Date: 2024.03.06 16:00:36 -05'00'
File details come from the government source that posted it. Updated .